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Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 10 out of 10 patient medical records (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed with negative outcome for 1 out of 10 patients medical records (Patient 2) reviewed.

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 10 out of 10 patient medical records (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed.

Findings include:

1. Facility policy titled, "Patient Rounding and Observation", Policy No.: NR.23. last revised 03/2024, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period.

2. Review of Patient 1's medical record from 06/07/2024 to 06/7/2024, lacked documentation of 659 of 955, 15-minute patient observation checks, including but not limited to, 06/07/2024 at 8:45 p.m., 06/11/2024 at 4:30 a.m., 06/13/2024 at 4:30 p.m., and 06/16/2024 at 10:00 a.m.

3. Review of Patient 2's medical record from 06/12/2024 to 06/19/2024, lacked documentation of 480 of 707, 15-minute patient observation checks, including but not limited to, 06/13/2024 at 8:45 p.m., 06/14/2024 at 7:30 p.m., 06/18/2024 at 8:00 p.m., and 06/19/2024 at 6:45 p.m.. Medical record indicated last 15-minute patient observation check on 06/19/2024 was at 6:31 p.m., Medical record lacked 15-minute patient observations between 6:45 p.m. to 8:30 p.m. on 06/19/2024. At approximately 8:30 p.m. on 06/19/2024, the patient was found in their bed covered in blood from a self-inflicted injury that resulted in the patient removing their left eye from the eye socket and had made an attempt to remove their right eye.

4. Review of Patient 3's medical record from 05/20/2024 to 06/06/2024, lacked documentation of 1191 of 1536, 15-minute patient observation checks, including but not limited to, 05/21/2024 at 2:30 a.m., 05/23/2024 at 3:15 p.m., 05/29/2024 at 4:45 a.m., and 06/02/204 at 2:30 p.m.

5. Review of Patient 4's medical record from 05/31/2024 to 06/01/2024, lacked documentation of 83 of 180, 15-minute patient observation checks, including but not limited to, 05/31/2024 at 3:00 a.m., 05/31/2024 at 12:30 p.m., 06/01/2024 at 1:00 a.m., and 06/01/2024 at 5:30 a.m.

6. Review of Patient 5's medical record from 06/11/2024 to 06/21/2024, lacked documentation of 698 of 947, 15-minute patient observation checks, including but not limited to, 06/11/2024 at 06/12/2024 at 1:30 a.m., 06/13/2024 at 2:30 p.m., 06/17/2024 at 11:30 p.m., and 06/18/2024 at 1:15 p.m.

7. Review of Patient 6's medical record 06/05/2024 to 06/25/2024, lacked documentation of 1283 of 1915, 15-minute patient observation checks, including but not limited to, 06/07/2024 at 3:30 a.m., 06/13/2024 at 8:00 p.m., 06/18/2024 at 11:45 a.m., and 06/23/2024 at 12:30 p.m.

8. Review of Patient 7's medical record from 06/14/2024 to 06/25/2024, lacked documentation of 682 of 1088, 15-minute patient observation checks, including but not limited to, 06/15/2024 at 5:30 a.m., 06/19/2024 at 7:45 p.m., 06/21/2024 at 4:45 p.m., and 06/24/2024 at 9:30 a.m.

9. Review of Patient 8's medical record from 06/18/2024 to 06/25/2024, lacked documentation of 362 of 736, 15-minute patient observation checks, including but not limited to, 6/18/2024 at 5:00 p.m., 06/21/2024 at 8:00 p.m., 06/23/2024 at 6:15 p.m., and 06/24/2024 at 10:00 p.m.

10. Review of Patient 9's medical record from 06/18/2024 to 06/25/2024, lacked documentation of 396 of 709, 15-minute patient observation checks, including but not limited to, 06/18/2024 at 10:15 p.m., 06/20/2024 at 1:30 p.m., 06/22/2024 at 5:30 a.m., 06/24/2024 at 9:45 a.m.

11. Review of Patient 10's medical record from 06/18/2024 to 06/25/2024, lacked documentation of 333 of 713, 15-minute patient observation checks, including but not limited to, 06/18/2024 at 5:30 p.m., 06/19/2024 at 8:45 p.m., 06/22/2024 at 5:00 a.m., and 06/24/2024 at 10:00 a.m.

12. Interview with A2 (Regional Quality Manager) on 06/25/2024 at approximately 1:00 p.m. confirmed that patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10's medical record lacked 15-minute patient observation checks as mentioned above.